No more than 13% of patients with end-stage renal disease (ESRD) receive hospice services, which contrasts with the 23% of all Medicare decedents and 60% of those dying of cancer. This exploratory study intends to develop an intervention to increase access to hospice care; its goals are to improve the terminus of life for the large number of elderly people with ESRD and provide greater support for their loved-ones. In Phase I, nine focus groups and a qualitative analysis will be used to refine the intervention. In Phase II, a feasibility trial will examine the impact of the intervention with a quantitative analysis. Dialysis facilities providing hemodialysis to 529 prevalent and incident patients will be divided into a block of two intervention clinics and a block of two control clinics. Patients will be screened to identify those who have life-limiting illness by using nephrologist prognostic estimates, serum albumin levels, and the Charlson Comorbidity Index. A Renal Supportive Care Team consisting of staff members from community hospices and dialysis facilities will meet with patients and families to acquaint them with the option of hospice and to encourage reflection on goals for end-of-life care. The team will also provide educational outreach to the staff of facilities, e.g. hospitals, nursing homes, etc., where these patients commonly die, and explore ways to simplify and facilitate hospice referral. The intervention will be provided to the dialysis staff and to subjects (n=67) from the intervention block, while subjects (N=62) from the control block will receive usual care. During a 20 month data collection period, the circumstances surrounding all deaths will be examined, and the key outome variables will be the provision of hospice care and family support. The family perspective will be elicited through use of two standardized palliative care intruments, the FAMCARE and the FEHCI. Three-quarters of the more than 75,000 patients with ESRD who die this year will be over 65 years old; most of the deaths will be accompanied by pain and other distressing symptoms, and they will occur in institutional settings. Hospices are available throughout the United States, and they represent a valuable and underutilized resource for the provision of quality care of older patients with kidney disease. The study is intended to form the basis of a future, and more ambitious multicenter research investigation (an R01) to examine whether increased use of hospice services improve ESRD quality-of-life and end-of-life care. [unreadable] [unreadable] [unreadable]